Healthcare Provider Details

I. General information

NPI: 1245295609
Provider Name (Legal Business Name): PETER MARK BRIDGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 MEDICAL CARE DR
BRANDON FL
33511
US

IV. Provider business mailing address

608 MEDICAL CARE DR BLDG 7-601
BRANDON FL
33511-5937
US

V. Phone/Fax

Practice location:
  • Phone: 813-684-2506
  • Fax: 813-684-5785
Mailing address:
  • Phone: 404-842-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME79084
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: